In this detailed guide, revered endodontist Dr Adi Moran shares his expert insight on the causes of dental pain and when to see a specialist about tooth ache. The leading specialist also details the key factors involved in performing successful root canal treatment, and shares key advice on seeking out a top quality practitioner.
Where does dental pain originate from?
In order to understand dental pain, we need to understand a bit about our anatomy. There is the crown of the tooth, which is essentially what you see when you look inside your mouth. Inside the tooth, there is also the root or a number of roots, as well as nerves and blood vessels. This tissue is called the pulp of the tooth.
In a healthy tooth without any decay, the pulp is completely sealed off from the oral environment by the crown, meaning that infection from the mouth cannot get in. Therefore, the inside of the tooth is completely sterile: no bugs, no viruses, no fungi and no microbes. On the other hand, if there is any way for infection to get inside, such as very deep decay, a fracture line, or a very deep restoration, then the nerves and the pulp tissue can become inflamed and develop into a source of pain.
There is another area, located right at the root canal, at the bone below the tooth, which can cause pain. If the irritation in the pulp tissue is there for long enough, or the pulp tissue dies and infection invades, this can progress down into the bone below. This means that the bone becomes irritated and inflamed, causing pain.
These two principal locations: the nerves and pulp, and the bone itself can both cause pain but will also usually provide completely different symptoms.
What are the causes of dental pain?
First of all, it's important to realise that not all conditions requiring a root canal treatment are actually painful. Some patients are in fact completely pain free though they still require root canal treatment.
Symptoms vary from person to person and not all conditions will feel the same to all patients. Very broadly speaking, if the nerves are inflamed to an extent where the body can still heal itself (i.e. you have some decay and perhaps some sensitivity to hot, cold and sweet foods and drinks) you may not require a root canal treatment yet. In contrast, when there is spontaneous pain which comes on at any time, or is provoked by drinking hot or cold drinks, the nerves and pulp are inflamed to an extent where root canal treatment is required. This pain may be very severe or throbbing at times, with some patients unable to localise its source within that side of the face, the ear, up to the eye or head.
When the inflammation progresses down into the bone, if the tooth is dead or there is an abscess, the pain will come from below, and will typically be more localised, constant and dull. In cases like these, the patient would know exactly where their pain is coming from, as opposed to pain which originates in the nerves, which can be difficult to localise sometimes.
When should I see a specialist about my tooth ache?
Pain diagnosis is an artform. Clinicians have to consider many factors in order to formulate a diagnosis or a differential diagnosis. It's not correct to simply use a radiograph and x-ray to find out what the problem is. Instead, we have to take all factors into consideration.
It's important to listen to the patient's key complaints: what they feel, what they have to say and their description of the symptoms they are experiencing. This means we can ask questions accordingly which helps us to see where the diagnosis might take us. We then have to look at the dental history of the tooth, which is really important and unfortunately, is sometimes neglected. We then proceed to a clinical examination, in which we check several factors, each of which can lead us in different directions. Next, we look at the radiograph results. Sometimes we may even need to do additional radiographs, such as 3D scans, CT scans or other types of tests in order to be completely sure when formulating a diagnosis.
Clinically, we may perform tests with cold temperatures if we suspect that the nerves are inflamed, or knock on the tooth, press on the gums, or “check pockets” to assess the connection between the gums and the teeth. We will also assess the mobility of the tooth, sensitivity, swelling and so on – it’s a very multifactorial process.
It's important to realise that we need a lot of information in order to begin to understand what the problem is and formulate a correct diagnosis, or a differential diagnosis which gives several options of what the patient may have in order of likelihood.
What is your advice for patients requiring treatment for dental pain?
Generally speaking, every dentist should be more than capable of performing a root canal treatment, especially if it is a simple case. That being said, randomised controlled trials of the highest rigour do show that specialists have a higher success rate in performing the exact same treatment.
If you require a root canal re-treatment or if there is a complication in the initial root canal treatment, that is definitely the time to see a specialist. Bear in mind that with today's knowledge, we know that the root canal anatomy inside the tooth is very complex and in order to be able to perform a root canal treatment to the highest quality of care, we need to use high power magnification. This essentially allows us to look inside the root canal system and I would urge patients who require root canal treatment to consult with a dentist who uses a dental operating microscope where the magnification is substantially higher than with more basic equipment.
Additionally, with today's knowledge in performing root canal treatments, which is vast, we need to use a lot of gadgets and technology. Not all general practitioners would have such a wide spectrum of different gadgets and instruments available, which are all crucially important and would be required in various scenarios. These modern gadgets are available in a specialist’s office. Generally speaking, if there are any complications, or if you or your dentist feel that extra management is required, it's time to see a specialist.
If you wish to schedule a consultation with Dr Moran, visit his Top Doctors profile today.